The Greek roots of the term euthanasia denote “good death.” Though it is common to think of death as unequivocally bad—it is, after all, our most severe punishment—one can easily distinguish between dying processes that are mercifully tolerable and others that are agonizing beyond endurance. During the events of 9/11, scores of people trapped in the World Trade Center leaped out of windows to escape the heat and smoke, some holding hands with others as they fell. Presumably, knowing their lives had come to an end, they chose deaths better than the ones they would suffer if they remained inside. Though it was tragic that so many luckless people met death in this way, few, if any, publicly argued that it was impermissibly wrong.
Euthanasia requires a second person’s involvement. In these so-called mercy killings, one person acts for the benefit of another. Many people think that, except for self-defense and a few other cases, it is a grave wrong to cause the foreseeable death of another human being. But one can imagine oneself struggling through the heat and smoke to reach a window at the World Trade Center. A coworker who uses a wheelchair is also there, but unable to get past the debris and into the air outside. She asks for your assistance. Now if it is permissible to do some one thing oneself, why would it not, by implication, be equally permissible to lend assistance to one who reasonably desires to do that same thing but is unable to do so?
Euthanasia, as an ethical problem, focuses on whether and, if so, when killing another person can be excused or justified on the grounds that it benefits the person killed. Except in some European countries, euthanasia is a crime. Those who end the lives of the intractably suffering, even when they follow urgent requests, will be charged with homicide. Should the law be changed to permit some beneficent killings?
Three issues muddy the waters. First, “euthanasia” was the euphemism the Nazis used to sanitize their early extermination of those they deemed defective. The program quickly evolved to kill millions: Jews, Romani, homosexuals, Communists, and more. Treated as vermin, the people involuntarily and secretly gassed in the concentration camps were not killed beneficently. “Involuntary euthanasia”—killing another against his or her will—seems a contradiction in terms. While some fear that loosening the law of homicide will send us down the slippery slope to holocaust, such prognostications require careful examination.
The second issue concerns what some still call “passive euthanasia”: the discontinuation of life-prolonging measures, often the removal of a ventilator (a mechanical breathing device). When a patient or an authorized proxy withdraws consent to treatment, then doctors, no longer at liberty to continue, may lawfully withdraw life support, causing death. Some maintain these patients die from their underlying diseases rather than from the doctor’s action. But if death is a foreseeable consequence, then the clinical removal of a ventilator kills a patient just as surely as the removal of a regulator kills a deeply submerged scuba diver. The law of homicide already includes this exception for doctors, and much of the literature on death and dying treats the patient’s legal and ethical power to refuse treatment. Although withdrawing life support can sometimes avert suffering, this strategy is often unavailable and the deaths so obtained may not be as tolerable as those medically induced. Nonetheless, it is nearly everywhere unlawful to administer medications for that purpose. Should this be changed?
The third issue, physician-assisted dying, refers to doctors who provide the means to end life: commonly a prescription and special instructions. Such assistance is legal in Oregon. Note that the doctor does not take the final, life-ending step. Should we amend the law on homicide to permit beneficent killing?
Suffering commonly affects patients with progressive illness—metastatic cancer, multiple sclerosis, Huntington’s disease, and so on—where the diagnosis is firm and the prognosis dire. Patients often understand what lies in store. Much of the euthanasia literature fixates on pain, and the sufferings brought on by severe illness come in many flavors: dizziness, diarrhea, disfigurement, itching, insomnia, incontinence, exhaustion, strains upon relationships, shortness of breath, anxiety, cognitive impairment and dementia, debt, depression, disabilities of all kinds, dependency, loss of control, nausea, offensive odors, and the losses of dignity that can accompany these.
Sometimes—but not always—symptoms can be managed while preserving positive elements that give value and richness to a waning life, for example, talking with loved ones, listening to music, or enjoying a sunset. But residual abilities too can succumb, even as a patient retains sensitivities that can make life intolerable. One strategy is “terminal sedation.” Doctors render a patient unconscious while withholding nutrition and hydration: Death ensues in a matter of days. However, not every patient prefers such “care” to a timely passing. There is a difference between having a life and being (biologically) alive: The former—the life one has—may be of supreme value to a patient. As with those trapped on 9/11, that life can come to an end before death occurs.
When a human life deteriorates to the point where one reasonably desires to end it, the argument for the permissibility of euthanasia turns on autonomy, that is, the ethical and legal power, within civic constraints, to chart the course of one’s own life, especially in areas where the stakes that others have in one’s action are not as great as one’s own. The root political idea is that, unless sound and proportional countervailing reasons exist, adults should be free to make their own choices. The presumption is in favor of liberty, that is, the liberty of informed, suffering, competent individuals to choose the manner and time of their death. In the face of intractable suffering and an expressed and settled preference for death, advocates argue strongly (a) that voluntary euthanasia should be permitted and (b) that it is cruel to prohibit charitable assistance to those who are relevantly similar to the luckless coworker in her wheelchair. Those acting out of compassion in these cases are surely not the criminals we have in mind when we build prisons. Accordingly, public policy should regulate, but not prohibit, voluntary euthanasia.
The second type of case occurs in the context of medical catastrophe. During a disaster the flow of patients into a hospital can temporarily exceed its carrying capacity. Doctors then focus on the patients who will likely live if treated but die if untreated, setting aside those without life-threatening injuries and those who will likely die despite treatment. They do not abandon this last group—”expectant” patients commonly identified with black tags—but give only ongoing comfort care (pain medications) and medical reassessment, especially if they unexpectedly survive the period of scarcity.
During forced military retreats and sometimes massive civilian disasters like Hurricane Katrina, health care settings can collapse catastrophically and care professionals and their patients can be compelled to evacuate. Should it prove impossible to relocate black-tagged patients, physicians have only three choices:
- They can, at great personal risk, stay behind with these doomed individuals even though there is little or nothing that can be medically done for them. By abandoning other treatable patients, health care professionals may be violating obligations toward them.
- They can abandon the black-tagged patients, leaving them to die unmedicated and unattended (or, during forced military retreats, in the hands of the enemy), thereby violating legal and ethical obligations toward those patients.
- They can beneficently kill expectant patients who cannot be evacuated. Patients able to decide could opt for abandonment, but those incapable of giving and withholding consent would receive nonvoluntary euthanasia.
This situation highlights two weighty medical norms: the prohibition against killing patients and the prohibition against abandoning them. Where it is impossible to evacuate patients and too dangerous to remain with them, one of the two norms must give way. Given this tragic moral uncertainty, it seems both compassionate and reasonable for the law to refrain from condemning those who try heroically to render honorable assistance under these rare but appalling circumstances, even though they deliberately end the lives of some.
Objections to Euthanasia
It is useful to distinguish between “yellow-light” objections (urging caution) and “red-light” objections (admonishing one to stop): Euthanasia can be said to pose a risk of adverse consequences or it can be said to be impermissible on its face.
There are many yellow-light objections. This is a slippery slope down which we can slide to holocaust. Compassionate homicide might erode the professional commitments of physicians as well as our trust in doctors. Patients could be depressed or pressured at the time of decision, or misdiagnosed, or haste in ending patients’ lives could prevent possible recoveries, or relatives and health care providers might conspire to end the lives of the ill, or protective measures might be unequal to the task of preventing carelessness and misconduct. The definitive assessment of these objections requires that we examine the effectiveness of specific protections. Here the Oregon record, as it becomes available, and the experience of the Dutch, Belgians, and Swiss become useful. Unlike the Nazis, we can require publicity in the implementation of protocols. Should adverse consequences occur following legalization, they must be measured against the adverse consequences of prohibition.
Many red-light objections emerge within particular religious traditions. These we can set aside because, in a pluralist society, the arguments that settle important public issues should be ones that can persuade any reasonable person, not just those who embrace some sectarian view. The sectarian arguments often maintain that human life is sacred and not to be discarded lightly. But if the closely related idea of human dignity can somehow be given a secular interpretation— one that is broadly persuasive and sufficiently weighty—and if the favored understanding of that idea somehow precludes euthanasia, then it may be reasonable to keep the law of homicide as it is. Again, such arguments require close examination.
The problem of euthanasia arises in extreme circumstances. In the first case, the life of a suffering person approaches a ruinous and horrific end. In the second, a collapsing health care system is unable to minister to the most grievously afflicted. It is distressing to ponder what it is like when such important matters go so dreadfully awry and to discern our responsibilities when they do. But such tragedies do befall us, challenging our capacities to craft decent and just social practices and to act rightly out of charity, compassion, and respect.
- Battin, Margaret P. 2000. The Least Worst Death: Essays in Bioethics on the End of Life. New York: Oxford University Press.
- Brock, Dan W. 1992. “Voluntary Active Euthanasia.” Hastings Center Report 2(March/April):10-22.
- Dworkin, Ronald. 1993. Life’s Dominion: An Argument about Abortion, Euthanasia, and Individual Freedom. New York: Knopf.
- Foot, Philippa. 1977. “Euthanasia.” Philosophy and Public Affairs 6(Winter):85-112.
- Kipnis, Kenneth. 2003. “Overwhelming Casualties: Medical Ethics in a Time of Terror.” Pp. 95-107 in In the Wake of Terror: Medicine and Morality in a Time of Crisis, edited by J. Moreno. Cambridge, MA: MIT Press.
- Rachels, James. 1986. The End of Life: Euthanasia and Morality. New York: Oxford University Press.
- Sulmasy, Daniel P. 1994. “Death and Human Dignity.” Linacre Quarterly 61:27-36.
- Swann, Steven W. 1987. “Euthanasia on the Battlefield.” Military Medicine 152:545-49.
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